Index

A

Adult vaccination, 177

coverage levels, 4, 29, 69, 87, 217– 220

current schedule, 21, 55

disparities in coverage, 4, 69–70, 218

federal government, 205, 219

high-risk populations, 4, 29, 87, 205, 218–219

immunization program needs, 2, 15, 195, 205, 219–220, 224

insurance coverage, 72, 77, 87, 89, 144–145, 219

Medicaid coverage, 83–84, 87–89

Medicare coverage, 86

Medicare spending, 8, 94–196

Section 317 program for, 90, 219

Adverse reactions, 60

Advisory Committee on Immunization Practices (ACIP), 14, 15, 21, 23, 55, 57, 64, 71, 74, 77, 78, 106, 125, 157, 205, 224

implementation of recommendations, 78–79, 98– 99, 201

recommendations for adult vaccination, 89

Aid to Families with Dependent Children, 35

Alabama, 50, 201

Alaska, 37, 78, 106, 218

American Academy of Family Physicians, 23, 57

American Academy of Pediatrics, 23, 24, 51, 55, 57, 74, 125

American Association of Health Plans, 51

American Medical Association, 57

American Samoa, 27

Antibiotic resistance, 59

Arizona, 218

Arkansas, 67

Assessment, assurance, and policy development

government role, 11, 103

national immunization strategy, 2, 39–43

private-sector role, 104

See also Infrastructure, public health



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Calling the Shots: Immunization Finance Policies and Practices Index A Adult vaccination, 177 coverage levels, 4, 29, 69, 87, 217– 220 current schedule, 21, 55 disparities in coverage, 4, 69–70, 218 federal government, 205, 219 high-risk populations, 4, 29, 87, 205, 218–219 immunization program needs, 2, 15, 195, 205, 219–220, 224 insurance coverage, 72, 77, 87, 89, 144–145, 219 Medicaid coverage, 83–84, 87–89 Medicare coverage, 86 Medicare spending, 8, 94–196 Section 317 program for, 90, 219 Adverse reactions, 60 Advisory Committee on Immunization Practices (ACIP), 14, 15, 21, 23, 55, 57, 64, 71, 74, 77, 78, 106, 125, 157, 205, 224 implementation of recommendations, 78–79, 98– 99, 201 recommendations for adult vaccination, 89 Aid to Families with Dependent Children, 35 Alabama, 50, 201 Alaska, 37, 78, 106, 218 American Academy of Family Physicians, 23, 57 American Academy of Pediatrics, 23, 24, 51, 55, 57, 74, 125 American Association of Health Plans, 51 American Medical Association, 57 American Samoa, 27 Antibiotic resistance, 59 Arizona, 218 Arkansas, 67 Assessment, assurance, and policy development government role, 11, 103 national immunization strategy, 2, 39–43 private-sector role, 104 See also Infrastructure, public health

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Calling the Shots: Immunization Finance Policies and Practices Assessment and feedback intervention, 42, 134–135, 139, 179 Association of Maternal and Child Health Programs, 51 Association of State and Territorial Health Officers, 51 Autism, 125–126 B Belau, 27 Birth rate, 4, 19 Bush administration, 35–36 C California, 83, 115, 147, 201 See also Los Angeles, San Diego Capitated payments, 62, 63, 67, 83, 85, 147 Carryover of funds, 51, 180–183, 191 n.6, 192 n.14, 203 Carter administration, 35 Case studies, 51, 263–270 See also specific site Centers for Disease Control and Prevention, 2, 5, 8, 26, 64, 79, 113, 119, 125, 168, 175 adult vaccination role, 6, 33, 193, 217, 220 control of disease outbreaks, 35– 36, 105–106 global polio eradication initiative, 183 grant administration, 27–28, 160– 161, 203, 208, 215 immunization project grants, 27– 28 immunization surveillance initiatives, 116, 117, 157, 184 incentive grants, 180, 210 infrastructure grants, 10, 90, 202 monitoring of disease reports by, 107 pockets-of-need strategy, 178–180, 192 nn.12–13 in projecting vaccine purchase needs, 14–15, 195, 223–224 provider definitions, 141 n.9 responsibilities, 91, 177 in Section 317 reauthorization, 214, 226 special population studies, 147 in state immunization programs, 6, 33, 160–161, 163, 165, 196, 216–217 state match requirements, 212–213 See also Section 317 program Chicago, Illinois, 27, 30, 35, 67, 69 Child care centers, 133 Client-held medical records, 138 Clinical Assessment Software Application, 110, 113–114, 115, 157, 191 n.5 Clinics, public health, 8, 129–130 client trends, 166 educational intervention in, 137 historical role in immunization, 40, 142–143 immunization costs billed to client insurance carrier by, 94– 95 limitations on free vaccination in, 97–98 referrals from managed care settings to, 62–63, 129–130, 166–168 role of, 40–41, 62, 99–100, 166 Section 317 spending by local health departments, 153 Clinton administration, 35, 117 College student immunizations, 55, 106 Community Health Network, 113 Community/Migrant Health Centers grants, 196 Congressional action, 176–177 recommendations for, 2, 195, 224, 225–226 Connecticut, 201 Cost of vaccine delivery components, 21–24, 41, 42, 71, 100 n.1

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Calling the Shots: Immunization Finance Policies and Practices to disadvantaged populations, 216 to final 10 percent of population, 47–50 full immunization, 94 local determinants of, 50 Medicaid coverage, 64, 78 Medicare reimbursement, 24, 86–87 obstacles to monitoring, 24–25, 122, 148 reimbursement issues, 63 VFC spending, 78 Cost of vaccines client out-of-pocket costs as barrier to immunization, 129– 130 determinants of, 100 n.1 full immunization, 21, 57, 94 influenza, 21, 89, 205 Medicaid coverage, 78 pneumococcal, 21, 89, 205, 227 n.4 public-sector discount, 21 trends, 57, 92 Council of State and Territorial Epidemiologists, 107 Coverage levels 1996 goals, 165 access to services as factor in, 133 accomplishments of national immunization program, 66 accountability issues, 150, 151 adult immunization, 4, 29, 69, 87, 217–220 among immigrant populations, 59–60 CDC pockets-of-need strategy, 178–180 challenges to improving, 4, 32, 146–148 client awareness intervention to improve, 136–138 cost determinants, 50 cost of achieving current levels, 19–29 current child levels, 19 current inadequacy, 3–4, 67–70 data sources, 110 disparities in adult vaccination, 69–70, 87, 218 disparities in childhood vaccination, 4, 29–31, 67–69 expanding access to services to improve, 129–133 extent of insurance coverage and, 74, 76–77, 144–146 focus on 2-year-olds, 19–21 goals, 1, 4 impact of budget reductions, 185 improving, 47 measurement methodologies, 110–115 in metropolitan areas, 4, 29–31 needs and performance measures, 17, 123, 146, 210, 226–227 NVAC recommendations to improve, 145 perceived acceptable levels, 108– 109 potential scope of federal programs, 81–83 private-sector immunization delivery and, 9, 151 as private-sector performance measure, 146 provider-based interventions to improve, 133–136 reducing client costs to improve, 129–130 risk of outbreaks, 3, 34–36 role of national immunization system, 6, 43–46, 47 role of registries in documenting, 116–117 role of registries in improving, 117 strategies to improve, 47, 128–129, 138–139, 151, 154 system-level interventions to improve, 139–140 variation by state, 60, 67

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Calling the Shots: Immunization Finance Policies and Practices D Dallas County, Texas, 67 Delaware, 116 Development of new vaccines, 46–47 safety testing, 126 Diphtheria surveillance, 107 vaccine, 55, 56, 66, 76–77 Disadvantaged populations, 177 cost of immunization, 216 disparities in coverage levels, 4, 29, 67–69 federal vaccine purchases for, 26, 38 health behavior, 216 monitoring coverage levels among, 63, 109, 113, 147 service delivery strategies, 178– 180 service delivery trends, 188–189 state responsibilities, 11 targeted service delivery, 47–50, 216–217 See also Pockets of need; Vulnerable groups Disease control and prevention component activities, 105–107 disease report investigations, 107– 108 government role, 65, 105–106 historical accomplishments, 18–19 impact of budget reductions, 183– 184 monitoring of disease reports, 107, 108 outbreak risk, 3, 34–36, 50, 108– 110 preventable mortality, 1, 4–5, 18, 29, 34, 35, 105 public health laboratory role, 107– 108 use of sentinels, 105 See also Monitoring of immunization status District of Columbia, 27, 93, 96 Drug resistant organisms, 59 E Educational interventions difficulties in, in current environment, 190 to increase community demand for vaccination, 136–137 by local health departments, 153– 154 private sector support for, 173 with providers, 135–136 Employee Retirement Income Security Act (ERISA), 75, 78, 101 nn.3–5, 145 Extra-immunization, 110 F Federal aid to states for adult vaccination, 15, 205, 219 budgetary cycles, 16, 182, 203, 207 current spending, 26, 194–196 distribution among states, 208 finance practices, 177–183 grant reporting requirements, 16, 207 inadequacies in, 41–43, 142, 174, 187–188, 189 incentive grants, 91, 111, 177, 180, 208, 210–211 infrastructure support, 2, 9–10, 157–161, 176–178, 182, 189, 200, 207 instability in, 9–10, 32, 220–221 interaction of federal immunization efforts, 38 local health department operations, 152–153, 154–156 policy issues, 5–6, 33, 193 potential coverage of immunization programs, 81–83 purpose, 7–8, 11, 38–39, 175–176, 215 recommendations for formula approach, 2, 16–17, 208–215, 225–226

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Calling the Shots: Immunization Finance Policies and Practices recommendations for infrastructure support, 2, 15– 16, 224–225 for vaccine purchases, 8, 163, 177– 178, 194–196, 200–201, 205 See also specific program Federal-state partnership accomplishments of, 3, 34, 66 basis for, 7–8 federal role, 38–39 goals for, 2 historical development, 39–40 information collection and management, 108 for infrastructure support, 108, 188 lack of strategic plan for, 5, 10, 32–33 Florida, 201 Formula for federal grants base grant, 208 incentive awards in, 210–211 methodology, 213–215, 216 population factors, 209, 216 rationale, 208 recommendations for, 2, 16–17, 225–226 state capacity and need considerations, 209–210 state match requirement, 16, 211– 213 G Georgia, 199 Global population movement, 59 Goals 1996 immunization targets, 165 accomplishments of national immunization program, 66 adult immunization, 69, 217 coverage levels, 1, 4 difficulties in achieving coverage goals, 146–148 for federal-state partnership, 2, 38–39 financial resources for achieving, 142 full immunization schedule, 19– 21, 55 National Immunization Program, 91 national immunization system, 6, 41, 43–46, 103–104, 193–194 for primary care delivery of vaccination, 144 vaccination access, 206 vaccine purchase, 206 Guam, 27 H Head Start, 153, 155, 202 Health Care Financing Administration, 8, 26, 64, 73, 146, 168, 202, 206 Health Insurance Association of America, 51 Health maintenance organizations, 62 implications for adult immunization, 219 quality assessment and improvement requirements, 146 Health Plan Employer Data and Information Set, 114, 115, 227 Health Resources and Services Administration, 175, 196 Healthy People 2000, 217, 218–219 Healthy People 2010, 144 Hepatitis A vaccine, 55, 56 Hepatitis B surveillance, 107 Hepatitis B vaccine, 15, 55, 76–77, 219 for adolescents, 57 cost, 57 Medicare coverage, 86 Medicare spending, 29, 86 Hold harmless provisions, 16, 225 Home visits, 132 Houston, Texas, 27, 30, 35, 67 Human immunodeficiency virus, 105

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Calling the Shots: Immunization Finance Policies and Practices I Immunization Action Plan areas, 111, 178–179 Incentive awards, 111, 180, 208, 210– 211 for client or family, 138 Section 317, 91 for states, 177 Indian Health Service, 196 Indiana, 67 Influenza surveillance, 107 Influenza vaccine, 76–77 adult coverage levels, 4, 29, 66–67, 69, 87, 89, 217, 218–219 child coverage levels, 66 cost, 21, 89, 205 coverage goals, 144–145 current recommendations, 21, 55, 57, 89 Medicare spending, 8, 26–29, 86 preventable mortality, 69 private insurance coverage, 76–77 recommendations for purchasing, 2 standing orders for, 135 Information management client-held medical records, 138 for disease control and prevention, 105–106, 108 disease report investigations, 107– 108 immunization registries, 116–122 in Medicaid, 63 in Medicare, 63, 87–89 monitoring of vaccine safety, 124– 128 in private sector, 63, 147–150 for public health infrastructure, 104–105 state efforts, 174–175 technical compatibility, 119 See also Monitoring of immunization status Infrastructure, public health components, 103–104 cost components, 21–24, 41 current instability, 1, 3, 204, 206– 207 definition, 104 effects of budget cutbacks, 168– 169, 173 evolution of immunization program in, 72, 143 federal responsibility, 11, 221–222 federal support, 9–10, 96, 157–161, 176–178, 185–186, 187, 202–203, 207 inadequate support for, 187, 188, 191 n.7, 207 information requirements for, 104–105 laboratories, 107–108 local health department roles, 152–156 nonfederal assistance to states, 203–204 private health care system and, 103, 143, 203–204, 206–207 recommendations for funding, 2, 15–16, 195, 207, 211–213, 224– 226 Section 317 grants for, 10, 91, 182– 183, 202–203, 207 state match requirements for funding, 2, 211–213, 226 state roles and responsibilities, 11, 140, 156–157, 222, 226 state spending, 161–163, 165, 173, 174, 175, 197–199, 202, 206–207 variation by state, 8–9, 50, 174, 199 See also Cost of vaccine delivery Insurance, private for adult vaccination, 72, 77, 87 capitated payments, 62, 63, 77, 83, 85, 147 immunization coverage, 15, 41, 62, 72, 74, 75, 76–77, 94, 144– 146, 191 nn.1–2 maintenance-of-effort requirements, 75–76, 76, 78 mandated coverage, 11–14, 74–76, 156, 205, 222–223

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Calling the Shots: Immunization Finance Policies and Practices role of, in national immunization program, 11, 14 state vaccine purchase and, 8 types of residual needs, 73 See also Uninsured and underinsured persons International immunization programs, 90, 177, 183, 187 L Laboratories, 107–108 Local conditions, 34, 47 cost of service delivery, 50 implications for expanding coverage, 165 responsiveness of immunization system, 221 Local health departments federal funding, 154–156 relations with state health departments, 155 roles and responsibilities, 153– 154, 199 structure and operations, 152–153 Los Angeles, California, 35, 67 Louisiana, 218 Lyme disease treatment costs, 107 M Maine, 51 Managed care, 34, 64 immunization data management, 25, 62, 114–115, 147–150 immunization service delivery, 62, 77, 85, 146–147 implications for adult immunization, 219 implications for public health infrastructure, 206–207 Medicaid enrollment, 62, 64, 83– 85 Medicare enrollment, 87 NVAC recommendations for, 145 obstacles to expanding coverage in, 146–147, 149 referrals to public clinics from, 62–63, 166–168 in SCHIP, 83 state-mandated services, 83 Mariana Islands, 27 Marshall Islands, 27 Massachusetts, 67 Maternal and Child Health Services grants, 10, 90, 161, 199, 209, 226 Measles outbreaks, 3, 34, 35–36, 106, 109, 133 Measles surveillance, 107 Measles, mumps, rubella vaccine, 55, 66, 70 insurance coverage, 76–77 safety concerns, 125–126 Medicaid, 9, 17, 26, 35, 37, 38, 63, 72, 74, 106, 109, 145, 160, 197, 199, 226 barriers to immunization access, 99–100 eligibility, 85, 156 enrollment, 77, 85, 94 funds for infrastructure support, 161, 196 immunization benefits, 41, 77–78 immunization spending, 26, 78 managed care enrollment, 62, 64, 83–85, 206 monitoring of immunization coverage in, 13, 63, 113, 187– 188, 210 obstacles to monitoring coverage in, 147, 149 outcomes and performance assessments, 146 potential participation, 81–83 residual need, 73, 211 state management, 50, 85, 146, 156, 163–164, 185, 200–201, 209–210, 213 Vaccines for Children program and, 64, 78–79, 97, 150, 221

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Calling the Shots: Immunization Finance Policies and Practices Medicare, 26, 63, 72, 74, 106, 188 adult vaccination coverage, 8, 26– 29, 194–196, 217, 219 immunization benefits, 86, 87, 89 information management, 87–89 managed care enrollment, 87 NVAC recommendations for, 145 vaccine reimbursement policy, 86–87, 102 n.23 vaccine spending, 24, 26–29 Meningitis surveillance, 107 Meningococcal vaccine, 55, 106 Metropolitan areas disparities in vaccination coverage levels, 67, 69 federal funding to, 152–153 Immunization Action Plans for, 178–179 monitoring coverage in, 148 recent measles epidemic, 35 vaccination coverage, 4, 29–31, 34 Michigan, 42, 117, 148, 201 Micronesia, 27 Migrant populations, 59–60, 94 Military personnel, 196 Monitoring of immunization status among disadvantaged populations , 63 challenges in, 60, 63, 122 client awareness intervention, 136 consistent and comparable measures for, 17, 123, 195, 226– 227 cost of records management, 24– 25, 122, 148 critical areas, 122–123 current inadequacies, 5, 32, 150– 151, 187–188 effects of local conditions, 47 future challenges in, 66 in high-coverage areas, 122 historical development, 108–109 identifying geographic pockets of need, 110 impact of budget reductions, 184, 190 importance of, 50, 124 in local health departments, 154– 155 measures for use in, 17 in Medicare managed care, 87–89 methodologies, 110–115, 123 private-sector immunization delivery and, 9, 14, 25, 63, 147– 148, 151–152, 189, 223 problems in data management, 63, 64, 119–122, 123, 139 rationale, 11, 122, 139, 222 recommendations for improving, 2, 17, 195, 226–227 small-area studies, 109–110, 112– 113, 123, 148 state efforts, 157, 160, 169, 174– 175, 190 state responsibilities, 156 surrogate measures, 110 tools for, 47 use of registries in, 116–117, 119 Monitoring of vaccine safety, 124–128 Mortality/morbidity disease trends, 18, 105 preventable infectious disease, 3, 4–5, 18, 29, 69–70, 105, 219 recent measles outbreaks, 3, 34, 35, 106 N National Association of City and County Health Officers, 51, 153, 155 National Association of WIC Directors, 51 National Committee for Quality Assurance, 114 National Conference of State Legislatures, 51 National Governors’ Association, 51 National Immunization Survey, 110, 111–112, 184, 227 National immunization system accomplishments of, 3, 18–19, 34, 54, 66–67

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Calling the Shots: Immunization Finance Policies and Practices ambiguities in leadership and administration, 65–66, 143, 174 complexity of, 47–50, 54, 61, 65–66 current inadequacy, 3–5, 10–14, 29–33, 34–36, 54 dynamic nature, 43 federal role, 11, 34, 36–37, 38–39, 64, 65, 174, 175–177, 215, 221, 222 fundamental roles, 6, 43–46, 47, 103–104, 193–194 future challenges, 60–61 historical development, 39–43, 54 impact of budget reductions, 183– 185 infrastructure efforts in, 103–104 instability of, 1, 3, 10, 220–221 institutional relationships, 64, 65– 66 need for comprehensive strategy, 10–11, 32–33, 221 policy issues, 5–6, 33, 193 private sector role, 11–14, 34, 64, 143, 144, 174 public agencies and organizations in, 64, 175 state role, 11, 34, 64, 65, 174, 221, 222 National Notifiable Disease Surveillance System, 107 National Vaccine Advisory Committee, 31, 145, 150, 179 purpose, 35 National Vaccine Injury Compensation Program, 126– 128, 196 Native American, 37, 78 Nevada, 218 New Jersey, 50, 67, 85, 218 see also Newark New York, 21, 27, 151, 218 Newark, New Jersey, 67, 148 North Carolina, 51 NVAC. See National Vaccine Advisory Committee O Outbreak risk, 3, 34–36, 50 clinical conceptualization, 108– 109 pockets of need and, 109–110 P Pennsylvania, 201 Pertussis surveillance, 107 vaccine, 56, 66, 76–77 Pneumococcal vaccine, 17 n.2 cost, 21, 89, 205, 227 n.4 coverage goals, 144–145 coverage levels, 4, 29, 69, 86, 217– 218 Medicare spending, 8, 26–29, 86 pediatric, 57 preventable mortality, 69 recommendations for adults, 21, 55, 89 recommendations for purchasing, 2 standing orders for, 135 Pockets of need, 4 federal infrastructure investments in immunization of, 176–177, 178–180 obstacles to identifying, 60 outbreak risk and, 109–110, 119 surveillance methods, 110 VFC effectiveness in, 37 See also Vulnerable groups Polio, 18, 56, 66 surveillance, 107 worldwide eradication efforts, 177, 183, 187 Population movement, 59–60 Prevention. See Disease control and prevention Primary health care delivery of immunizations in, 62, 72, 223 goals for immunization delivery in, 37, 144

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Calling the Shots: Immunization Finance Policies and Practices monitoring of coverage levels in, 189 preventive services in, 189 Private health care system accountability for immunization coverage, 146, 150 adult vaccination coverage in, 144–145, 188 contributions to state infrastructure, 203–204 cost of vaccines, 21 federal action in, 177 immunization data management, 114–115, 149–150 interaction with federal immunization efforts, 38, 62– 63, 64 mandated coverage, 222–223 monitoring of immunization status, 9, 14, 17, 63, 147–148, 149–150, 151–152, 189, 223 in national immunization program, 11–14, 34, 40–41, 43, 143, 144, 150, 174, 222 NVAC recommendations for, 145, 150 opportunities for improving coverage in, 152 public health infrastructure and, 103, 206–207 public health partnership, 151 quality assessment and improvement programs, 146, 189 referrals to public vaccination programs from, 129–130 service delivery in, 8, 61–63, 72, 129–130, 166, 188, 189, 200 state management and oversight of, 157–160, 177 See also Insurance, private; Managed care Public awareness and understanding of immunization status, 136 obstacles to, in current environment, 190 safety of vaccines, 128 Public Health Service block grants, 161, 196 Puerto Rico, 27 Q Quality assessment and improvement, 146 R Race/ethnicity disparities in adult vaccination coverage, 4, 69–70, 87, 218 disparities in child vaccination coverage, 67 Registries of immunization, 157, 204 barriers to development and implementation, 119–122, 124 benefits, 119, 123–124 compatibility issues, 117, 119–122 definition, 116 efforts to date, 116–117, 123 fully functional, 141 n.6 funding for, 184 ideal components, 117 national system, 117 provider participation, 117 role in improving coverage levels, 119 Reminder-recall intervention client, 136, 139, 154, 179 provider, 134 Reminder-recall-outreach intervention, 151 Residual needs, 94 determinants of, 99–100 examples of, 73 federal funding for, 15, 224 future challenges, 98–99, 205–206 state responses, 11, 100, 164–165 See also Disadvantaged populations; Pockets of need; Uninsured and underinsured persons; Vulnerable groups Rhode Island, 67

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Calling the Shots: Immunization Finance Policies and Practices Rotavirus vaccine, 56, 125, 201 Rubella infection, 107. See also Measles, mumps, rubella vaccine S Safety of vaccines, 47, 177 adverse events, 60, 124–125, 126, 127, 141 n.11 monitoring, 124–128 public awareness and understanding, 128 San Antonio, Texas, 27 San Diego, California, 51 Schedule of vaccinations, 46–47 changes in, implications for service delivery, 14–15, 60–61, 66, 190, 195, 223–224 concerns of universal purchase states, 98 current, 21, 55 delay between vaccine approval and availability, 60, 79, 100 provider reminder-recall, 134 rate of change in, 55, 57 recent changes in, 55–57 state requirements, 137, 145–146 SCHIP. See State Children’s Health Insurance Program School-based immunization, 112, 132– 133, 156 Section 317 program, 112, 152, 188– 189, 194 accomplishments of, 8 administrative problems for states, 203 adult vaccination funding, 90, 219 budget cutbacks, 168–169, 176, 177–178, 182–183, 190, 203 carryover of funds, 51, 180–183, 203 current funding mechanism, 27– 28, 90 formula funding mechanism, 2, 16–17, 195, 208–215, 216, 225– 226 historical development, 89–90 immunization coverage under, 90–91 incentive awards, 91, 210–211 infrastructure grants, 2, 10, 90, 91, 157–161, 165, 176, 177–178, 182–183, 185–187, 187, 200, 202–203, 207 interaction of federal immunization efforts, 38, 97, 99 level of funding for, 90, 185 local health department funding, 153 outbreak control funding, 183–184 pockets-of-need strategy, 178–180 policy issues, 5–6, 33, 193 program operations, 90, 185–186 provisions, 17 n.1 purpose, 26, 36–37, 43, 72, 89–90, 91–92, 176, 199, 209 reauthorization, 214, 226 recommended funding for, 2, 14, 15, 195, 207, 224 resource allocation, 38, 91, 165, 177–178, 185–187, 200, 202 SCHIP and, 38, 51, 196 special population studies under, 147 state match requirements, 9, 212 vaccine purchases, 8, 61, 90–91, 95, 177–178, 200, 201, 223–224 VFC program and, 38, 90 Section program, 2, 5 Settings for immunization comparisons of coverage, 110 current distribution, 61–62 dispersion of responsibilities, 64 historical evolution, 39–41 implications for monitoring coverage, 63, 64, 122 nonmedical, 131–133 primary care provider, 62 private sector, 61–63, 188 service delivery trends, 8, 188 strategies for expanding access, 130–131

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Calling the Shots: Immunization Finance Policies and Practices Small-area immunization studies, 109– 110, 112–113, 123, 148 Smallpox, 18, 57–59 Social benefits of immunization, 71 Social service programs access to immunization in, 131– 132 identifying underimmunized populations through, 35 linkage with immunization program, 32, 41, 154, 155 state infrastructure funding from, 161 Socioeconomic status disparities in vaccination coverage levels, 4, 29, 67, 129 obstacles to improving coverage disparity, 32 trends, 166 utilization of public clinics, 129– 130 Standing orders, 135 State Children’s Health Insurance Program (SCHIP), 9, 17, 26, 41, 74, 143, 145, 149, 154, 160, 206 capitated insurance programs and, 83, 85 coordination with other vaccine programs, 185, 211 coverage policies, 83, 101–102 n.17 enrollment trends, 62 grant allocation, 79 interaction of federal immunization efforts, 38, 83 managed care arrangements, 83 monitoring of immunization coverage in, 187–188, 210 performance monitoring, 109 policy issues, 5 potential participation, 81–83 public health infrastructure support in, 196 purpose, 38, 79, 106, 196 residual need, 72, 73, 94, 211 Section 317 and, 38, 51, 196 state administrative practices, 79– 81, 85, 146, 156, 180, 209–210, 213 Vaccines for Children program and, 166, 202, 221 State immunization programs administration of local health departments, 153 adult vaccination, 224 allocation of federal funds among, 208 core functions, 43, 160–161 current inadequacy, 1, 32, 174 current obstacles to service delivery, 189–190 efficient use of federal funds, 210– 211 eligibility for free vaccines in, 97– 98 federal infrastructure grants, 9– 10, 13 federal role in, 7–8, 175–176 finance practices, 163–168, 182 future prospects, 1, 190–191 impact of budget reductions, 183– 185 infrastructure problems, 204 infrastructure spending by, 2, 8–9, 29, 50, 161–163, 174, 175, 197– 199 linkage with other service programs, 32 Medicaid administration, 78, 146 policy issues, 5–6, 33, 193 private-sector management and oversight, 157–160 quality assessment and improvement programs, 146 recommendations for adult vaccine spending, 2, 15, 195, 224 recommendations for infrastructure funding, 2, 15– 16, 195, 207, 224–225 recommendations for monitoring, 2

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Calling the Shots: Immunization Finance Policies and Practices recommendations for Section 317 funding mechanism, 2, 16–17, 208–215, 225–226 required vaccination, 137, 145–146 requirements for private insurance coverage, 74–75 requirements for private-sector data management, 149 resource allocation, 100, 157–161, 163–164, 165–166, 169, 173, 180, 197–199, 200–201 response to budget reductions, 9– 10, 168–169, 173, 174, 180, 189, 203 response to residual needs, 11, 100, 164–165 roles and responsibilities, 7, 156– 157 SCHIP administration, 79–81 Section 317 grants, 90, 91–92, 157– 161, 165, 182–183, 185–187, 199, 203 vaccine purchases, 2, 8, 10, 29, 61, 91–95, 163, 196–199, 200–201, 205 variation by state, 8–9, 49–50, 60, 67, 93–95, 164–165, 174, 199 VFC provisions, 78–79, 95–97, 166 T Task Force on Community Preventive Services (TFCPS), 128–129, 130–131, 132, 133, 134, 135–136, 137, 138, 139 Temporary Assistance for Needy Families, 161 Tetanus surveillance, 107 Tetanus vaccination, 15, 55, 56, 66, 76– 77 adult booster, 219 Texas, 67 See also Dallas County, Houston Thimerosal, 125 Title V grants, 196 Tuberculosis, 59 U Uninsured and underinsured persons current estimates of, 74, 77, 94 high-risk adults, 87 private health care enrollment, 94 recommendations for funding, 15 residual need, 94 SCHIP for, 38 vaccine delivery, 8 VFC program for, 37, 78, 95, 96 Universal purchase programs, 8, 72, 97, 201, 202 cost of additions to immunization schedule, 98 Utah, 201 V Vaccine Adverse Events Reporting System, 126 Vaccine purchases current inadequacies, 1, 205–206 federal programs, 36, 37, 61, 64, 187 federal spending, 8, 26–29, 194– 196, 205 projected needs, 14–15, 195, 223– 224 recommended federal funding for, 14, 15, 195, 224 role of national immunization system, 6, 43 under Section 317, 90–91, 177–178, 200, 201 Section 317 savings for states, 200 state immunization programs, 163 state spending, 8, 10, 29, 61, 91– 97, 196–199, 200–201, 205 under VFC program, 78, 81, 187, 223–224 See also Cost of vaccines Vaccines for Children (VFC) program, 8, 9, 26, 36, 64, 72, 74, 92, 129, 145, 154, 160, 166, 188–189, 194 accomplishments, 37

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Calling the Shots: Immunization Finance Policies and Practices administrative costs, 201–202 coverage policies, 78, 83, 95, 101 nn.10–11, 221 enhanced programs, 96 future challenges, 98–99 health care provider enrollment, 63, 78 increases in coverage associated with, 130 interaction with other vaccination programs, 38, 83, 97, 166, 185 limitations, 37, 43, 85, 180 Medicaid and, 64, 78, 79, 97, 150, 166, 200, 221 monitoring of immunization coverage in, 187–188 performance monitoring, 109 potential participation, 81–83 prior to, 92 provider participation, 64 purpose, 37, 43, 72, 78, 161 recommended federal funding, 14, 223–224 referrals, 129–130 requirements for states, 78–79 residual need, 73, 94, 98–99 resource management by states, 161, 163–164 role of public health agencies in, 143 SCHIP and, 166, 202, 221 Section 317 program and, 38, 89 vaccine purchase savings for states, 93, 97, 200 vaccine purchases, 26, 61, 78, 93, 95, 223–224 Varicella vaccine, 55, 56, 77, 79 cost, 57 coverage rate, 60 delays in availability, 60, 79, 100 Vermont, 67 VFC. See Vaccines for Children program Virgin Islands, 27 Vulnerable groups, 33 monitoring coverage in private sector, 9, 63, 147, 149–150, 151, 152 monitoring needs, 66, 151 service delivery trends, 188–189 state role in monitoring, 11 surveillance methods, 112–113 trends, 66 See also Disadvantaged populations; Pockets of need W Washington, 111–112, 201 West Nile-like virus, 59 Women, Infants, and Children (WIC) program, 10, 32, 35, 41, 64, 131–132, 138, 153, 154, 155, 157, 161, 199, 202 in CDC interventions in low-coverage areas, 179–180